结直肠腺瘤切除后病理诊断升级的危险因素分析

Analysis of risk factors for pathological diagnosis upgrading after resection of colorectal adenoma

目的:探讨影响结直肠腺瘤切除术后病理诊断较术前升级的危险因素。方法:纳入2017年1月至2022年12月在宁夏医科大学总医院行内镜下钳夹活检术(EFB)、经EFB病理检查诊断为结直肠腺瘤后行腺瘤切除的1059例患者,将EFB标本与腺瘤切除后标本的病理诊断进行比较后分为病理无差异组(1003例)和病理升级组(56例),比较两组患者的临床资料和腺瘤的内镜特征,临床资料包括吸烟史、结直肠癌家族史等,腺瘤内镜特征包括腺瘤最大径、形态特征、表面是否凹陷、是否糜烂或溃疡、表面颜色等。统计学方法采用卡方检验或Fisher确切概率法。采用多因素logistic回归模型分析腺瘤切除后病理诊断升级的危险因素。结果:病理升级组中有吸烟史、结直肠癌家族史、合并高血压、合并冠心病的患者比例高于病理无差异组[46.43%(26/56)比26.12%(262/1003)、8.93%(5/56)比0.70%(7/1003)、46.43%(26/56)比30.11%(302/1003)、21.43%(12/56)比9.27%(93/1003)],差异均有统计学意义(χ^(2)=11.05,Fisher确切概率法,χ^(2)=6.61、8.78;均P<0.05)。病理无差异组与病理升级组腺瘤的最大径[<20 mm者分别有929例(92.62%)和23例(41.07%)、≥20 mm分别有74例(7.38%)和33例(58.93%)],形态特征[有蒂者分别有220例(21.93%)和28例(50.00%)、无蒂者分别有783例(78.07%)和28例(50.00%)],表面颜色[近正常黏膜者分别有347例(34.60%)和3例(5.36%)、发红者分别有613例(61.12%)和50例(89.29%)、发白者分别有43例(4.29%)和3例(5.36%)],糜烂或溃疡情况[糜烂或溃疡者分别有78例(7.78%)和36例(64.29%)、无糜烂或溃疡者分别有925例(92.22%)和20例(35.71%)],以及表面凹陷情况[凹陷者分别有6例(0.60%)和8例(14.29%)、不凹陷者分别有997例(99.40%)和48例(85.71%)]比较,差异均有统计学意义(χ^(2)=155.18、23.30、20.58、176.31,Fisher确切概率法;均P<0.001)。多因素logistic回归模型分析结果显示,腺瘤表面凹陷[OR=25.198,95%置信区间(95%CI)5.812~109.246,P<0.001]、糜烂或溃疡(OR=9.913,95%CI 4.652~21.124,P<0.001)、表面颜色发红(OR=4.276,95%CI 1.053~17.363,P=0.042)、表面颜色发白(OR=8.803,95%CI 1.398~55.435,P=0.021)、最大径≥20 mm(OR=4.689,95%CI 2.265~9.706,P<0.001),以及有结直肠癌家族史(OR=8.764,95%CI 1.418~54.162,P=0.019)、吸烟史(OR=2.713,95%CI 1.376~5.349,P=0.004)均是腺瘤切除后病理诊断升级的独立危险因素。结论:腺瘤表面凹陷、最大径≥20 mm、糜烂或溃疡、表面颜色发白或发红,以及患者有结直肠癌家族史、吸烟史都可能会增强腺瘤的异质性,干扰EFB病理的精准度,导致术后病理诊断升级。

Objective To investigate the risk factors that affected pathological diagnosis upgrading after resection of colorectal adenoma.Methods From January 2017 to December 2022,a total of 1059 patients who underwent adenoma resection after pathologically diagnosed as adenoma by endoscopic forceps biopsy(EFB)were included in General Hospital of Ningxia Medical University.The patients were divided into the pathologically no difference group(1003 cases)and the pathologically upgraded group(56 cases)based on the comparison of pathological diagnosis of EFB specimens and the specimens after adenoma resection.Clinical information and endoscopic characteristics of the adenoma were compared between the 2 groups.The clinical information included smoking history,family history of colorectal cancer,and the endoscopic characteristics included maximum diameter,morphological characteristics,surface depression,erosion or ulceration,and surface color of adenoma.Chi-square test and Fisher′s exact test were used for statistical analysis.Multivariate logistic regression model was used to analyze the risk factors for pathological diagnosis upgrading after adenoma resection.Results The proportions of patients with smoking history,family history of colorectal cancer,concomitant hypertension,and coronary heart disease in the pathologically upgraded group were higher than those in the pathologically no difference group(46.43%,26/56 vs.26.12%,262/1003;8.93%,5/56 vs.0.70%,7/1003;46.43%,26/56 vs.30.11%,302/1003;21.43%,12/56 vs.9.27%,93/1003),and the differences were statistically significant(χ^(2)=11.05,Fisher′s exact test,χ^(2)=6.61 and 8.78;all P<0.05).There were statistically significant differences between the pathologically no difference group and pathologically upgraded group in the maximum diameter(929 cases(92.62%)and 23 cases(41.07%)of<20 mm,and 74 cases(7.38%)and 33 cases(58.93%)of≥20 mm,respectively),morphological characteristics(220 cases(21.93%)and 28 cases(50.00%)with pedicle,and 783 cases(78.07%)and 28 cases(50.00%)without pedicle,respectively),surface color(347 cases(34.60%)and 3 cases(5.36%)of near normal mucosa,613 cases(61.12%)and 50 cases(89.29%)of red surface color,and 43 cases(4.29%)and 3 cases(5.36%)of white surface color,respectively),erosion or ulceration(78 cases(7.78%)and 36 cases(64.29%)had erosion or ulceration,and 925 cases(92.22%)and 20 cases(35.71%)had no erosion or ulceration,respectively),and surface depression(6 cases(0.60%)and 8 cases(14.29%)of depression,and 997 cases(99.40%)and 48 cases(85.71%)of non depression,respectively)(χ^(2)=155.18,23.30,20.58 and 176.31,Fisher′s exact test;all P<0.001).The result of multivariate logistic regression analysis showed that surface depression(OR=25.198,95%confidence interval(95%CI)5.812 to 109.246,P<0.001),erosion or ulceration(OR=9.913,95%CI 4.652 to 21.124,P<0.001),red surface color(OR=4.276,95%CI 1.053 to 17.363,P=0.042),white surface color(OR=8.803,95%CI 1.398 to 55.435,P=0.021),maximum diameter≥20 mm(OR=4.689,95%CI 2.265 to 9.706,P<0.001),family history of colorectal cancer(OR=8.764,95%CI 1.418 to 54.162,P=0.019)and smoking history(OR=2.713,95%CI 1.376 to 5.349,P=0.004)were independent risk factors for pathological diagnosis upgrading after adenoma resection.Conclusion Surface depression,maximum diameter≥20 mm,erosion or ulceration,white or red surface color,family history of colorectal cancer and smoking history may enhance the heterogeneity of adenomas,interfere with the accuracy of EFB pathology,and lead to an upgrade of pathological diagnosis after adenoma resection.